We need health care instead of disease management

I always wanted to become a medical doctor to cure the sick and save lives. In fact, most doctors I know chose the profession for the same reason. This fundamental desire among physicians to treat patients is because our beliefs have been deeply rooted in the concept of disease management rather than the provision of health care.

As an aspiring physician and student of health care, I often catch myself heading to the physician’s office to be treated for a condition, rather than prophylactically for health maintenance. When I get to the doctor’s office I end up seeing the doctor for what seems like only a few minutes, before they write me some prescription and hurry me out of the office for the next patient to come in.

Interestingly, my health insurance will cover and reimburse such on-demand sick visits and prescriptions more readily than frequent health and wellness checkups where I am simply able to sit down and talk to my doctor about my health goals.

With rising costs, expanding patient populations, shortages of physicians and nurses, and the growing prevalence of chronic diseases, I have to question if doctors have it right.  Is it better to cure the sick, or instead focus on enabling a nation of the healthy?

I started to think about this when I co-led a group of 40 students on a medical brigade to the Panamanian jungle recently. I envisioned us setting up our clinic to treat the sick in the classic U.S. “conveyor-belt” style, with patients moving from triage to consultation to dental to patient education and finally to pharmacy to pick up their meds. I thought that by doing so, we would effectively manage diseases, cure the sick, and save lives. I was wrong.

On my first day of clinic, no patients showed up. Rather than sitting around in the consultation room doing nothing, I decided to spend the day playing with children in the playground.

I was upset. I had expected to be the “doctor,” to give out medicines, to feel like I was making a difference. Instead, I used my time to swing from monkey bars in the playground with healthy children who had nothing to do and no place to go. I felt like I was making no impact at all.

When I arrived to the clinic the next morning, something happened that made me change my mind. Waiting for me at the entrance was a young Panamanian child named Michael, with whom I had spent the previous day playing. When I got off the bus, Michael ran up to me, gave me a hug, called me his “amigo,” and pulled out a cake from his lunch bag, which he gave to me as a present.

Immediately, I choked up — here was a child who lived in extreme poverty and did not know when his next meal would be, yet he valued the time and attention I had given him so much that he gave me the cake his parents had packed for him. That’s when it hit me, that a simple gesture of attention to one who needed it was making as much difference in the provision of care as any medicine could … maybe even more.

Following this experience, I pushed to abandon the conveyor belt philosophy for a new way of thinking in managing patients. While I knew that disease management would be inevitable, my goal was to focus on health care. I was lucky. A few doctors in my brigade felt the same.

As an observer, my most memorable case of witnessing meaningful health care was a woman complaining of headache caused by stress. After some probing, she revealed that her twins had passed, and she could no longer have any more children. Since she now only had one living son, she was too scared to let him leave the house for fear of something happening to him, and this contributed to her headache.

This woman clearly did not want nor need medicine; she just needed someone to talk to, someone to listen and just let her know she was being cared for. She left the clinic that day a healthy and hopeful woman, having received 50 minutes of one-on-one quality care with a physician. While she instigated the visit because of illness, the greatest benefit to treating her was simply to provide empathy first, followed by a plan for her health care that she could agree to and follow.

Benjamin Franklin once said, “The best doctor gives the least medicines.”  During my week in Panama, I learned that the fundamentals of medicine do not lie in giving out millions of medications and seeing as many patients as possible, but rather in instilling in patients the vision for their own health by providing them a compassionate ear, professional guidance, and quality time.

Above all else, this is what medicine must be about.

Robert G. Dorfman is a medical student.

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  • guest

    This is just fantastic, you are absolutely right about what it is that medicine should be all about.

    Tell me, what is it that you plan to do once you are a doctor, to bring about change in our healthcare delivery system in order to make sure that doctors have enough time with their patients to provide the type of care you are describing? What are you suggestions for how we can move towards that goal? Because I’m pretty sure that relocating to Panama and volunteering to work with indigent Panamanians, although emotionally satisfying, won’t help pay off your medical school loans.

  • buzzkillerjsmith

    If you are talking about primary prevention, you are wrong about all this, and you will discover that fact over time. Mostly our job is patch people up.

    Why this that? The most important preventive measure can be done by the nurses or the MAs: immunization. Prevention’s effectiveness goes way, way down from there.

    I will allow that secondary through quarternary prevention are in our bailiwick.

    Your job, young med student, is diagnosis and treatment. Although prevention of disease is a worthy goal, it is mostly for society and it is really beyond the individual physician’s power to get it done. If you’re interested in population health, your success as a doc will be limited. Go into politics instead.

    It is curious how when you look at it all from a distance it looks so easy. It’s not that way. Patch ‘em up as best you can.

    • NPPCP

      A lot of preventive services outside of what you talk about are easily known by people if they want to know with the advent of the internet. I’m with you on the immunizations, etc. The med student is trying to figure out a way to do it all. You can’t. It’s impossible. That’s one reason why the medical home will never work. Humans have a free will and are not amenable to coaching and finger pointing most of the time. “New healthcare” does require that we point out the fact that a lot of the responsibility for health is on the patient. It’s not our job to follow them around with a biannual EMR alert telling them it’s time for a colonoscopy. It’s just all too much.

      • https://www.facebook.com/arobert6 Alice Robertson

        I think it’s neat that you are young enough to realize the sheer joys of a patient doing their own research, and your understanding and appreciation of that. Go back a few years here and see doctors going bonkers over such a thing. It would add to their workload, cause all types of confusion…an apocalypse that would wreck their very lives. Patients were like, “Really? I just want to understand.” I remember a doc writing in TIME magazine that he punted a patient after she told him to be careful because there would be a traffic jam on his way home…yep she knew where he lived. Ha!

      • buzzkillerjsmith

        You are correct, sir or madam.

    • Mengles

      Well he is a medical student, so as well know well from their essays on KevinMD, they know SO MUCH more than experienced doctors. The only reason we haven’t been able to do so is bc we’re not trying hard enough.

      • Chiked

        Buzzkillerjsmith was once a medical student. BFD. Sometimes you need an outsider to solve a problem.

        • Mengles

          A medical student isn’t an outsider. Of course you also think we should ban things so whatever.

    • https://www.facebook.com/arobert6 Alice Robertson

      Buzz: You are right on many levels…yet, there’s just something nice here in this article.. What if a patient wants the metaphorical heart “patched up”? That’s really quite a task, but it’s also why a personal letter from a doctor to a patient’s family can go viral when it shows compassion. Sorry but my posts are moderated if they go much longer than this. I will post the second part. below…..

      • https://www.facebook.com/arobert6 Alice Robertson

        Part 2:

        Years ago it was considered pandering by doctors to appeal to a
        societal type of outlook…but now with the internet surely your average
        patient is at least aware that their actions are causing problems.
        But, therein, lies the problem. Is it easier to patch up, or chaff
        up…or deliver the naked truth with a velvet glove! ha!

      • buzzkillerjsmith

        Showing compassion, which I heartily endorse, is treatment, not prevention.

        • https://www.facebook.com/arobert6 Alice Robertson

          Fair enough on the distinction….but sometimes I sorta feel bad for the doctors here who are shooting themselves in the foot from a PR standpoint. This thread is sorta bad timing for me with a biopsy for my daughter on Tuesday. I NEED to like doctors….I NEED to trust them implicitly….gosh what terrible PR these threads begin to look like. Can’t you just tell us sweet little lies and at least make us think we matter and that you care?

          • buzzkillerjsmith

            Hi Alice,
            I do care-for my patients. No one at this blog is a pt of mine, at least as far as I know. To me this is a public blog in which people can express their opinions freely, and a blog like that is important. It’s important for us docs and for you patients, at least those of you who are interested in these matter.

            That said, I will allow that docs being honest, even anonymously, is not for everyone.

    • Chiked

      Sorry doc. I disagree that prevention can be done equally well by a nurse or MA. You only say that because you do not understand the critical role of preventative medicine.

      The diagnose and treat model that you speak of does not work for diabetes, heart disease, cancer, obesity amongst others. These diseases cannot be “treated” with a pill. So if you do not develop the skill of preventative medicine, you are an endangered specie.

      • NPPCP

        It’s really not preventive medicine. It’s teaching someone to fish. There are lots of caregivers who do this; for instance, dieticians. Over half of the newly diagnosed diabetics in my clinic don’t want t go to dietary counseling. We aren’t going to be having the time to do all of that. No one does. And by “no one”, what I actually mean, is NO ONE. Physicians don’t have the time, NPs don’t have the time RNs don’t have the time. And none of us are endangered. The diseases you mention are “personal responsibility diseases”. Yes, they can be treated with pills, but only for a little while. And trust me, buzz understands a lot of things; and preventive care, or lack of the time to adequately provide it is one of them.

        • Chiked

          You know, a lot is made about patient responsibility and I get it. But a lot of doctors/NPs are complicit in this nonsense. Why do you send a diabetic patient to see a dietician? As I understand, diet and lifestyle is probably the most critical aspect of dealing with diabetes. Since you know the patient’s entire medical and social history shouldn’t you be the one in charge of this aspect? And yes it cannot be done in 15mins. But whose fault is that?

          The point I am making is that preventative medicine or what you call teaching them to fish takes time and is impossible to incorporate in our 15 min per patient appointments. NPs and all other practitioners should examine their role as well instead of always blaming it on patient responsibility.

      • PoliticallyIncorrectMD

        Perhaps you can enlighten everybody on how to prevent cancer, heart disease and diabetes.

        • Chiked

          It is simple. Eat organic foods, avoid ALL processed sugars, chemical lotions or creams and get lots of sleep. Our bodies are not beta prototypes. They have been around and tested for thousands of years. Give it what it wants and you can avoid most diseases.

          • PoliticallyIncorrectMD

            Genius! I wish we’ve met before I wasted years in medical training! Why don’t you, then, solve all the healthcare problems, and we, endangered species, hang around just in case this turns out to be little more complicated than you think.

          • buzzkillerjsmith

            About 25% of early humans lived past age 40, with all that organic food and such. Maybe they should have tried inorganic.

          • PoliticallyIncorrectMD

            Genius! I feel sorry we haven’t met years ago before I wasted years getting my medical training. Why don’t you then fix all the problems of the healthcare, while we, the endangered species, hang around, just in case it is not as simple as you think.

          • Chiked

            Don’t fret. Your years of training were not wasted. You are just another hapless victim of big Pharma’s marketing machine.

            Once you realize that most of the time the human body is pretty good at taking care of itself, you will discover the real role a doctor should play.

        • byustudent

          Avoiding diabetes is pretty damned easy, there are very few genetic causes. Diet may be tricky but it’s totally doable. Cancer? Well, not so easy. Heart disease? A little more predictable than cancer. Why is everyone such a defeatist?

          • Guest

            But does one really need an incredibly expensive medical doctor to tell one these things, or can one read it in a flyer or on the internet, or be told it by a computer kiosk?

            Face it, most people KNOW they shouldn’t eat sugar and fat and salt all day long, but they do it anyway. How is paying medical doctors megabucks to sit down and tell these heedless people what they already know anyway, going to do any good? Except for the megabucks doctors’ bank accounts, that is?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    No it isn’t. You don’t need to go to medical school in order to befriend children or be kind to distraught mothers who lost their children, and for whom there is absolutely nothing you can do (unless you are a psychiatrist, and even then…).
    Most people don’t go to the doctor to find out if cheesecake makes them fat, or if smoking is bad for them, or to be enlightened about swimming pool safety for toddlers, or to make new friends. They mostly go to a doctor because they are hurting in some way, or they don’t want to be hurting in the future. Your job is to diagnose and treat the immediate problem for the human being sitting across from you. Sometimes it takes lots of listening and talking and sometimes it takes chemical compounds and sometimes knives are required. It’s your job to figure out which one it is and administer it. And it’s your job to do it in a compassionate and personal way.
    Public health, health policy, education, public assistance and all those other things are somebody else’s job. If you like these things better, or if you think they are more important (and they very well may be in the long run), then by all means go do them.
    Medicine is for the sick, and will probably be so for many years to come (until all mysteries are solved), and medicine is not about “disease management” either. It’s about caring for people who happen to have a disease.

    • NPPCP

      I agree with you Margalit. Part of being a primary caregiver, whatever our stripe, also sometimes consists of letting people know they have no disease. Or making sure they DON’T have a disease and then leading them in the right direction from there. I treat so many people in my clinic by comforting them or doing nothing for them, or steering them in the right direction. Yes I use a scalpel or a medication. But there is a lot more to it than that. :)

  • May Wright

    “This woman clearly did not want nor need medicine; she just needed
    someone to talk to, someone to listen and just let her know she was
    being cared for.”

    So she needed a social worker or a counselor, not a medical doctor.

    • https://www.facebook.com/arobert6 Alice Robertson

      I have dealt with a social worker. You walk into a neurologist office and a social worker stands there while the doctor tells you they can’t help your child….your child will die. The social worker could hardly speak. It’s simply not that easy and the patient (or mom) leans heavily on the doctor at that time.

      • NPPCP

        Absolutely. There is a time for a social worker or other caregiver. But lots of patients don’t know WHEN that time is. We, as primary caregivers, are there to help them with that.

        • https://www.facebook.com/arobert6 Alice Robertson

          I don’t know about that….I hear your plea and we should give empathy if we expect it. But gosh I have had wonderful caring physicians who do provide it. I can’t post anything long here because I get moderated and the post hasn’t shown up. I will try to post my comments in snippets. I have had two children with cancer so I know doctors on a level I wish I didn’t, but I can say truly some of them really do exactly what this article is emphatically trying to say. I say a “Bravo!” to this author and really think you are right it’s a strong call but this is where May messed up because if a social worker can do it w/o medical expertise so can any human being.

      • Tiredoc

        There are some jobs that a human shouldn’t be allowed to receive training in. Social work is one of them. Comforting the bereft is a calling by God, and is not trainable. Most social workers in training I just want to shout in their face, “Why did you think you were suited for this?”

    • Suzi Q 38

      Why, are physicians “Dr. Spock. from Star Trek??”

      • Guest

        Paying for a medical doctor to have 50-minute chats with people who don’t need medical care is like hiring specialist F-1 pit crews to service your fleet of golf carts. It’s overkill, it’s a waste. If you are paying for it, go ahead and hire whoever you want to listen to you whinge and moan. But don’t expect me to pay for it. We have limited health care dollars, and this is not a judicious use of them.

  • Mengles

    Before even reading down to the last line, I could 100% tell this was written by a beginning medical student (if not a premed), due to all the logical fallacies stated.

  • Steven Reznick

    The compassion and idealism of the author are wonderful. The commitment to service and stewardship is additionally wonderful. Learning what your patient needs takes listening and time in addition to the technical skills of physical examination and at times well chosen labs and imaging. I think we are all being too rough on a student. It would be interesting to review this article and the authors mindset after the author completes their first year of residency. Students should be wide eyed and idealistic at this stage. I am more concerned by articles on this blog written by business executives who speak as if they actually understand what patients and physician’s feel and should be doing. Blogs from the ACP and AMA usually consist of similar drivel. This article is from a well meaning caring student. Give the author a break please

  • Anthony D

    “With rising costs, expanding patient populations, shortages of physicians and nurses”

    “I have to question if doctors have it right.”

    On Fri, September 20, 2013. Yahoo Finance posted in article called,

    “$1 Million Mistake: Becoming a Doctor”.

    Its a fantastic article that everyone should read and how doctors feel stuck with their rising and struggling costs in their debt and in health care! Its also discusses job dissatisfaction among certain specialties, and in internal medicine!

    If you highlight it and put it on either Yahoo or Google. Its a great article for us members to read!

  • Jean Oliver

    In an ideal world doctors would, indeed, exist only to treat sickness, disease, etc. and not provide preventive services in the form of lifestyle coaching. If individuals took care of themselves as they should through proper lifestyle choices a lot of doctor care would be eliminated. Doctors could concentrate on those who truly need it and not be using a lot of their time to manage patients who are “sick” due to lifestyle related diseases (type 2 diabetes, high cholesterol, high blood pressure, etc.) The whole problem as I see it is that a large number of people do not want to make wise lifestyle choices and, yes, they do know what they should be doing. Anyone who needs a doctor to tell them what healthy habits are is in denial or has been living under a rock. The information is out there in abundance: you don’t need to pay a doctor to find it out! But too many people just go on about their bad habits and want to be monitored and medicated by a doctor just so that they can go on that way. Can you imagine how much we could save in health care dollars if this whole problem would go away? It’s just not going to happen any time soon so there will always be this argument about a doctor’s role: lifestyle coach/disease manager or medical healer for the truly sick.

    • https://www.facebook.com/arobert6 Alice Robertson

      One of the top ten medical blogs had a line today (Musings of a Distractable Mind).
      This
      is why, I believe, any system that profits more from people
      with“problems” than those without is destined to collapse. Our system is
      opposed to the goal of every person I see: to stay healthy and stay on
      as few drugs, have as few procedures, and avoid as many doctors (and
      drug companies) as possible.
      What would happen if we prevented
      disease? What would happen if people didn’t have medical problems? For
      society it would be great. For the health care industry it would be a
      huge problem

  • medicontheedge

    Here comes the cynic:
    There is no PROFIT in “healthcare”. There is big profit in “disease management”.

  • guest

    The problem I see now is that the new insurance under Obamacare is not going to offer many choices and I would guess in many areas will be rendered almost ineffective. Meaning that the pay to physicians looks like it will be much less than commercial insurance. Concern then that doctors won’t take the insurance and many are left in the same boat.

  • Ruchi Saxena

    Wow! This is one article that I will share for the comments more than the article itself! There are some saying doctors job is to treat the sick and leave the patient care to someone else! Are we descendents of Hippocrates and Hutchison talking here or modern-age doctors who think their white coats are only brought to action for writing prescriptions and using scalpels? What’s our primary duty as physicians? Pass on the patient care to ‘social workers’???

    • Disqus_37216b4O

      Okay. Let’s say, as in the anecdote above, an indigent patient doesn’t need medical care but just wants a sympathetic ear for 50 minutes (that’s 4+ standard 12-minute appointment slots).

      Are you going to do it for free? Or are you going to demand to be paid, obviously not by the indigent patient, but out of the taxes of people who actually work for a living and do not have either the time or the money to spend 50 minutes bending a medical doctor’s ear?

      I pay cash for my appointments, a standard 12-minute is $60, so 50 minutes would be $250. I ask you again, are you going to do this for free, or are you going to demand $250 for what a priest or a minister would do for free? And from whom are you going to demand the $250? And how are $250 50-minute counseling sessions from medical doctors for people who don’t actually require the services of a medical doctor going to “bend the cost curve down” when it comes to America’s already sky-high ratio of GDP spent on doctors?

    • NPPCP

      Pass on appropriate care to social workers, yes. As a Nurse Practitioner, I do many things in my private clinic; some counseling, yes. But in depth counseling is sent to the experts – those specifically trained for this solemn duty. Not physicians, not other NPs, not even psychiatrists – social workers and counselors. Why? Time. Everyone is saying it over and over. Time and the desire to stay solvent to be able to take care of other patients.

      • Chiked

        Not enough time to check a blood pressure so you hire a medical assistant. Not enough time to talk about your lost spouse so you are sent to a psychologist. Having money stressors, not on my 15mins, we will send you to a financial counselor.

        Sooner or later, all you are good for is writing prescriptions and you do not need years of medical training to do that.

        • NPPCP

          Now, my friend, you are just being ridiculous. We talk about all those things and I do lots of them myself. But many things require much more intensive care. You realize all of this. So, relax. It’s all okay. You live longer without so much anger. Some things require specialty. It’s okay. I just make sure you get the best care I can provide if I am responsible for you – even if I am not the one providing it.

          • Chiked

            You show me how you can talk about any one of those things in 15 mins and I will seek anger management.

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